Assisted Living Facilities
| Author | Jeffrey Wilson |
| Pages | 1247-1254 |
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The concept of "assisted living" as a unique program of care or service for elderly/minimally impaired persons has been slow, in the eyes of legislators and practitioners, to distinguish itself from other existing forms of services. The distinction becomes important for purposes of funding and financial assistance from state and federal entities. But more importantly, the distinction becomes important in the eyes of the residents and their families.
Assisted living is often described as a statement of philosophy which differentiates itself from other forms of "residential care" by focusing on a model of living that promotes independence, autonomy, privacy, and dignity for residents in a facility. In other words, the concept relates more to an approach toward care rather than to the actual care received. Moreover, families struggling with the less appealing option of placing their loved ones in traditional "nursing homes" are more soothed by the option of knowing that assisted living strives to maintain the current level of independence enjoyed by residents, but with supervision or support when needed.
In general, the term "assisted living" is used transitionally with that of "board and care" services. However, assisted living statutes and regulations usually contain language referring to "independence," "autonomy," "privacy," etc. Assisted living is also different from other residential programs (e.g., homes for the aged, board and care facilities, residential care facilities, etc.) in that it is more likely to involve apartment-like settings and (if living space is to be shared) choice of apartment mates. Finally, assisted living facility staff will often make arrangements for external entities rather than internal staff members to provide nursing care or health related services to residents. This arrangement makes such services more likely to be reimbursable as "home health care services" under Medicaid or other funding initiatives.
But when assisted living residents need nursing care, the distinction between "assisted living" and other forms of residential care becomes more nebulous. In many states, assisted living facilities may admit or retain residents who meet "level of care" criteria used for admission to nursing facilities. At the same time, many nursing homes divide their beds into wards or designated areas, so as to accommodate varying levels of resident needs. They may have a skilled care area, an intermediate care area, and an "assisted living" area all within the same facility. Generally, such an arrangement is mutually beneficial to facility and patient. It keeps occupancy rates high at the facility and allows residents to move internally from one area of care to another without the need to move to another facility altogether.
Semantics aside, assisted living generally refers to a residential living arrangement in which residential
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amenities are combined with "as needed" assistance with "activities of daily living" (ADLs) (eating, dressing, bathing, ambulating, toileting, etc.) and personal care. Although only about half of all states actually use the term "assisted living" in their regulations or statutes, a vast majority of states have either reviewed existing legislation or enacted new laws to address the growing demand for assisted living facilities. This action occurred particularly during the years of 1995 through 2000.
All assisted living facilities accepting state or federal funds must be licensed. For those accepting federal funds, most of the applicable regulations and rules are incorporated into those applicable to nursing homes in general. They include:
The Nursing Home Reform Act is absorbed in a massive piece of legislation known as the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). The Act imposes more than just minimum standards; it requires that a facility provide each patient with a level of care that enables him or her "to attain or maintain the highest practicable physical, mental and psychosocial wellbeing." Importantly, OBRA 87 makes each state responsible for establishing, monitoring, and enforcing state licensing and federal standards. Under the Act, states must fund, staff, and maintain investigatory and Ombudsman units as well.
The Patient Self Determination Act of 1990 is absorbed in the Omnibus Budget Reconciliation Act of 1990 (OBRA 1990). Applicable to more than just nursing homes, it essentially mandates that facilities provide written information to patients regarding their rights under state law to participate in decisions concerning their medical care. This includes the right to execute advance directives and the right to accept or reject medical or surgical treatments. The facilities must also provide a written policy statement regarding implementation of these rights, and must document in each patient's record whether or not an advance directive has been executed.
States are required to effect bills of rights for nursing home residents. Generally, the same rights attach to residents in assisted living facilities as those in nursing homes. Most state declarations of rights parallel the federal ones, codified at 42 USC 1395i-3(a) to (h); and 1396r(a) to (h) (1988 supplement to the U.S.C.). They are enumerated in the section addressing nursing homes.
Public subsidies for elders in residential settings take different courses in different states. Older persons qualifying for low-income subsidies may apply their federal SSI benefits, as well as any state supplemental SSI benefits, toward assisted living charges for room and board. Medicaid generally pays for nursing or medical services provided to qualified individuals. In most states, this is done through Home and Community Based Services (HCBS) (Section 1915(c)) waivers. Waiver programs acknowledge that many individuals at high risk for being institutionalized can be cared for in their own homes or communities, thus preserving their independence and ties to family and community, at no more cost than that of institutional care. Thus, a person eligible for institutional care may "waive" that right and apply the funds toward home care or assisted living arrangements. Waivers are generally granted for three years and may be renewed for five years.
Finally, many states are developing policies that combine SSI with Medicaid benefits to provide one level of care appropriate for the resident. This encourages "aging in place" rather than the stressful alternative of finding another facility should the resident's health decline and he or she needs more than what assisted living can offer.
The following information summarizes state approaches to assisted living arrangements. The absence of certain information in the summary for a particular state (e.g. a mention of minimum staffing ratios or room sizes) is not to be construed as meaning that no requirements exist for that state regarding that element or factor. Rather, the information focuses on some of the important or distinguishing points from state to state.
ALABAMA: See Ala. Code Chapter 420-5-4. Revisions to existing regulations were issued in 1999. The
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state recognizes three categories of assisted living facilities: congregate (17 or more adults), group (4 to 16 adults), and family (2 to 3 adults). The regulations provide that residents must be "ambulatory adults who do not require acute, continuous, or extensive medical or nursing care and are not in the need of hospital or nursing home care." Staffing ratio requirements are one staff...
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